DENMARK CLINICAL PSYCHOLOGY INFORMATION & ADULT CONSENT

Patient Details
Name	Next of kin / phn
Date of birth	Emergency contact / phn
Address	Patient Medicare number
Phone	Referring medical practitioner
Email address	Medical practitioner address
Occupation	Legal proceedings current or pending? Please specify:
Living situation

Please read each section below and initial if you understand and accept. If you have questions about any section, please ask your therapist about it before your first session begins.

Initials
Why am I attending therapy? I am attending therapy at my own free will because I have issues or problems that I would like help with.
What is therapy? I will be going through an assessment process and will be asked personal questions about how I am feeling, what I do or have done, and about my personal history. My therapist will help me understand my stress or condition, why I have it, why it’s not improving without help, and the treatments that will help me to feel and function better.
What is the therapy process? I understand that a treatment plan will be discussed with me, sessions will be 55mins in duration, and it is likely that I will be asked to complete between sessions tasks that will help with my recovery or stress. All therapy content will be based on techniques supported by research evidence, however, recovery cannot be guaranteed.
Are there any negative side effects? I understand that sometimes talking about personal experiences and working with my therapist on sensitive issues can make me feel vulnerable and my functioning and sense of well-being can decline in the short term. I may feel some anxiety before, during, or between sessions. Traumatic experiences/memories may come to my attention. These effects are expected to improve and I will let my therapist know if they do not. Often there are risks associated with not engaging in recommended treatment: conditions may get worse; functioning may decline; levels of distress and effects on family can occur. If at any point, I feel an urge toward harming myself or others, I commit to calling emergency services and letting my therapist know. My therapist will discuss a safety plan with me, and I commit to following it in order to keep myself and others safe.
Is my information private? I understand that my therapist will store written/typed notes on session content and keep them locked and safe for a minimum of 7 years. Assessments results can be stored electronically with only initials. My therapist will provide summary review/progress information to my referring medical practitioner as required by Medicare Australia. My therapist may also discuss my treatment with peer support/supervisors on a no-names basis.
When might my private information be given to others? Any recordings/notes/letters/reports must be provided to the court if they are subpoenaed. Confidentiality will also be broken if there is any suggested risk of harm to myself or others. My therapist will call emergency services if risk is high or dangerous.
Can consent be changed or withdrawn? I understand that I can change my mind and withdraw from therapy any time. If I return after some time, consent to proceed will be sought again. If further assessment or a change in treatment plan is made, this will be explained and my verbal consent will need to be given. My consent will be sought annually if long-term therapy is provided.
Can my therapy be terminated by my therapist? I commit to having a respectful relationship with my therapist. I will not be verbally or physically aggressive at any time and I will respect communication boundaries as set by my therapist (e.g., SMS, email, phone calls). If this does not occur, my therapist will discuss it with me and if not resolved, I will be referred to another therapist.
What are the costs? Clinical psychology sessions cost $190 each. Medicare Australia rebates up to 10 sessions per year if a medical practitioner has lodged a Mental Health Care Plan. Rebates are $131.65. A gap fee of approx. $60 applies. Sessions are paid for via Eftpos on the day of service.

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